A cognitively intact resident with multiple chronic conditions, including COPD and chronic myeloid leukemia, was care planned to be encouraged to use the toilet for bowel evacuation, but staff followed Kardex instructions to use a bedpan and at times only placed incontinence pads under her instead. The resident reported to police that she had been left sitting in her bowel movement for several hours and that staff used chucks instead of a bedpan, causing discomfort and embarrassment. In interviews, she stated she preferred to be transferred with a lift to the toilet and had recently tolerated a sit-to-stand lift well. An LPN acknowledged miscommunication between shifts that led to the resident not receiving needed care and stated that residents required more attention than staff could provide, demonstrating a failure to provide dignified, care-planned toileting consistent with the resident’s preferences.
The facility failed to ensure resident dignity and self‑determination when a video camera with audio capability, installed by a resident’s POA in a shared room, remained in use without documented consent from either resident or their representatives. A cognitively impaired resident and that resident’s guardian were not properly informed of the camera’s presence, and the guardian later reported being unaware and uncomfortable with it. Record review showed no signed consent for the camera from the roommate’s POA and no documentation of any discussion at a care conference, and neither resident’s care plan addressed the ongoing audio/visual surveillance in the room.
A resident with dementia and age-related osteoporosis, who had severe cognitive impairment, was observed receiving personal care from a CNA while undressed, with the room door and privacy curtains left open, making the resident visible from the hallway. The CNA later admitted not providing privacy and dignity, and both the RN supervisor and DON stated that staff are expected to ensure privacy and appropriate coverage during care. Facility admission documents state that residents are to be afforded dignity, respect, and privacy in treatment and care for personal needs.
Surveyors observed CNAs standing over two dependent residents during meals and one CNA feeding both residents interchangeably, rather than providing individualized, seated assistance as required by facility policy. One resident had severe cognitive and physical impairments, including spastic hemiplegia, paraplegia, aphasia, and moderate protein-calorie malnutrition, and required max assist with eating. The other had encephalopathy, CKD, type 2 DM, adult failure to thrive, Alzheimer’s, dementia, depression, and anxiety, and was totally dependent on staff for eating. Despite care plans and care cards specifying one-on-one assistance, staff stood while feeding and alternated bites between the two residents, and later explained they did not see available seats, while the DON confirmed staff are expected to sit when feeding residents.
A resident with reduced mobility and muscle weakness, who was cognitively intact and care planned for assistance with toileting, activated a call light requesting help with a bedpan due to diarrhea and concern about soiling herself. Surveyors observed the call light on for 57 minutes before an ADON entered, asked what was needed, and provided assistance. During this period, multiple staff, including dietary and housekeeping personnel and a CNA responsible for the resident, entered or were aware of the situation but did not address the call light or provide the requested toileting assistance. This response time exceeded the facility’s stated expectation of responding to call lights within 15–20 minutes and did not follow the written call light procedure requiring timely response and completion of the resident’s request before turning off the call light.
A resident with progressive MS and intact cognition refused a new bed when the facility implemented a building-wide bed replacement, but staff and a corporate representative proceeded to replace the bed and mattress despite her objections. After the change, the resident repeatedly reported severe back and hip pain attributed to the new bed, and documentation showed a significant increase in pain scores and frequent PRN Norco use during this period. When staff later agreed to switch her back to an older bed, an ISW and housekeeping moved numerous personal items out of her room, and housekeeping unilaterally took some of these belongings to a garbage chute room without the resident’s consent, contrary to her care plan that directed staff not to remove items without her participation. The resident became visibly upset when she discovered missing items and reported that not all of her belongings, including a bag of snacks, were returned, demonstrating a failure to respect her dignity, self-determination, and property.
A resident with chronic health conditions and cognitive intactness requested that staff wear masks when entering his room, as indicated by signage. Multiple staff members entered without masks and did not ask for permission, and the resident confirmed this was upsetting. The resident's preference was not included in his care plan, and staff did not consistently respect his wishes, resulting in a failure to honor his right to self-determination and dignity.
Multiple residents experienced prolonged wait times for call light responses, with documented delays often exceeding 20 minutes and sometimes reaching up to 45 minutes. Residents with various medical conditions reported waiting for assistance, including during episodes of incontinence. Staff interviews and call light data confirmed that short staffing and lack of an effective alert system contributed to these delays, and residents expressed concerns about insufficient staff support.
A resident with multiple chronic conditions was not consistently allowed to eat in the dining room as per her documented preference, due to staff failing to coordinate her morning care and shower schedule. Despite her care plan and meal tickets indicating her choice, she was served breakfast in her room instead of the dining room, which was confirmed by interviews with the CNA, DM, and DON.
A resident with an indwelling catheter was observed in public areas with their catheter bag uncovered and visible to others on multiple occasions. The resident expressed a preference for privacy, and facility staff confirmed that catheter bags should always be covered in public spaces. These actions failed to uphold the resident's dignity and privacy.
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